Provider Demographics
NPI:1306048491
Name:RUSSELL, TIMOTHY WADE (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WADE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E. HAWKEYE AVE.
Mailing Address - Street 2:P.O. BOX 86
Mailing Address - City:REMSEN
Mailing Address - State:IA
Mailing Address - Zip Code:51050-0086
Mailing Address - Country:US
Mailing Address - Phone:712-786-2989
Mailing Address - Fax:712-786-2220
Practice Address - Street 1:325 E. HAWKEYE AVE.
Practice Address - Street 2:
Practice Address - City:REMSEN
Practice Address - State:IA
Practice Address - Zip Code:51050-0086
Practice Address - Country:US
Practice Address - Phone:712-786-2989
Practice Address - Fax:712-786-2220
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA0 5501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor